Sandbox pericarditis

Characterize the symptoms: ❑ Chest pain ❑ Sudden onset ❑ Sharp or dull, aching and pressure like ❑ Pleuritic (exacerbated by inspiration and coughing) ❑ Retrosternal ❑ Located in the trapezius muscle ridge ❑ Radiation to the neck or the arms ❑ Affected by position (improved by sitting up and leaning forward) ❑ No pain (uremia and tuberculosis pericarditis develop slowly) Symptoms associated with pericardial effusion: ❑ Without a hemodynamically significant pericardial effusion ❑ No specific symptoms ❑ With a hemodynamically significant pericardial effusion ❑ Fatigue ❑ Breathlessness ❑ Orthopnea ❑ Dizziness ❑ Hoarseness (recurrent laryngeal nerve compression) ❑ Hiccups (phrenic nerve compression) ❑ Abdominal pain (mesenteric ischemia) ❑ Nausea (diaphragm irritation) ❑ Loss of consciousness ❑ Cool extremities ❑ Peripheral cyanosis ❑ Peripheral edema Other etiology associated symptoms: ❑ Fever (suggestive of infectious etiology) ❑ Cough (suggestive of infectious etiology) ❑ Palpitations ❑ Malaise ❑ Joint pains (suggestive of autoimmune etiology) ❑ Odynophagia ❑ Weight loss (suggestive of malignant etiology)

Obtain a detailed history: ❑ Infections ❑ Pneumonia ❑ Tuberculosis ❑ HIV ❑ Travel history ❑ Travel to Central or South America (Chagas disease) ❑ Travel to Central Asia or South Africa or South America (Tuberculosis) ❑ Travel to North and Central America, such as Ohio and Mississippi River valleys (Histoplasmosis) ❑ Travel to North America (Blastomycosis) ❑ Medications ❑ 5-Fluorouracil ❑ Amiodarone ❑ Anticoagulants ❑ Cyclosporine ❑ Cyclophosphamide ❑ Cytarabine ❑ Daunorubicin ❑ Doxorubicin ❑ Drug-induced lupus erythematosus ❑ Methysergide ❑ Penicillins ❑ Sulfa drugs ❑ Thiazides ❑ Thrombolytic agents ❑ Systemic illness ❑ Collagen vascular disease ❑ Hypothyroidism ❑ Inflammatory bowel disease ❑ Malignancy ❑ Uremia ❑ Others ❑ Cardiac surgery ❑ Radiation exposure ❑ Dressler's syndrome ❑ Postpericardiotomy syndrome ❑ Trauma history

Examine the patient: Vital signs ❑ Pulse ❑ Tachycardia (typical) ❑ Bradycardia (in hypothyroidism and uremia) ❑ Pulsus paradoxus (in cardiac tamponade) ❑ Blood pressure ❑ Normal (typical) ❑ Hypotension (in cardiac tamponade) ❑ Temperature ❑ Fever less than 39°C or 102.2°F ❑ Hypothermic (in elderly and renal failure) ❑ Respiratory rate ❑ Tachypnea (typical) Cardiovascular system Auscultation ❑ Heart sounds ❑ Normal (typical) ❑ New S3 heart sound ❑ Distant and muffled (in cardiac tamponade) ❑ Murmur (in concomitant heart disease) ❑ Pericardial friction rub ❑ High pitched, scratchy or squeaky sound ❑ Best heard at the left sternal border ❑ Best heard with the diaphragm of the stethoscope ❑ Varies in intensity overtime and needs repeated examinations {{#ev:youtube|watch?v=EUCp_3_vwtw|300}} Palpation ❑ Jugular venous pulse ❑ Elevated (in cardiac tamponade and constrictive pericarditis) ❑ Kussmaul sign (in constrictive pericarditis) Percussion ❑ Cardiac dullness beyond the apical point of maximal impulse (in pericardial effusion) Respiratory system ❑ Wheeze or rales ❑ Pleural effusion Abdomen ❑ Pulsatile hepatomegaly (in constrictive pericarditis) ❑ Ascites

Order tests (Urgent): Order laboratory tests (urgent): ❑ CBC (leucocytosis) ❑ ESR (elevated) ❑ C reactive protein (elevated) ❑ Serum cardiac troponin I and T ❑ Creatine kinase (CK-MB) ❑ Serum myoglobin ❑ Serum tumour necrosis factor ❑ Serum urea and creatinine Order electrocardiogram (urgent): ❑ Typical findings in pericarditis ❑ ST segment elevation in leads I, II, aVL, aVF, and V3-V6 ❑ PR segment depression ❑ Low QRS voltage (in large pericardial effusion and constrictive pericarditis) ST elevation in leads I, II, V2, V3, V4, V5, and V6 depicting acute pericarditis ❑ Electrical alternans (in cardiac tamponade) Order imaging (urgent): ❑ Chest X-ray ❑ Clear lung fields (typical) ❑ A flask-shaped, enlarged cardiac silhouette (in pericardial effusion and cardiac tamponade) ❑ Lateral view may reveal ❑ Thickened pericardial line (in pericarditis, pericardial effusion) ❑ Irregular contours of cardiac silhouette (in chronic pericarditis, pericardial fibrosis, post surgery, metastasis) Pericardial effusion ❑ Echocardiography (diagnostic test of choice) ❑ Typical findings in pericarditis ❑ Presence of moderate and large pericardial effusion ❑ Right atrial collapse ❑ Diastolic collapse of right ventricle and left atrium (specific for cardiac tamponade) ❑ Check for concomitant heart disease or paracardial pathology

Does the patient have at least two of the following criteria for the diagnosis of acute pericarditis? ❑ Characteristic chest pain ❑ Sharp and pleuritic that is improved by sitting up and leaning forward ❑ Pericardial friction rub ❑ High pitched, scratchy sound at the left sternal border best heard with the diaphragm of the stethoscope ❑ Heard during atrial systole, ventricular systole and rapid ventricular filling in early diastole ❑ Suggestive ECG changes ❑ Diffuse ST elevation with reciprocal ST depression in leads aVR and V1 ❑ Suggestive echocardiography changes ❑ New or worsening pericardial effusion

Yes

No

Does the patient have any sign of myocarditis? ❑ Elevated cardiac enzymes, or ❑ Global or regional myocardial dysfunction on echocardiography

Does the patient have any signs suspicious of acute pericarditis? ❑ Ongoing fever ❑ Poor response to treatment ❑ Hemodynamic compromise

No

Yes

No

Yes

Acute pericarditis

Myopericarditis

Consider alternative diagnosis and treat accordingly

Consider cardiac MRI (CMR)

Treat as acute pericarditis or myopericarditis if there is delayed enhancement on CMR